The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|PRESENCE SAINT JOSEPH MEDICAL CENTER||333 N MADISON ST JOLIET, IL 60435||Feb. 15, 2012|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
A. Based on clinical record review and staff interview, it was determined that for 13 of 13 nurses (E#'s 8-20) who care for a postoperative heart patient (Pt.#8), the Hospital failed to ensure staff were trained in the use of a heart device (Tandem Heart).
1 The clinical record for Pt. #8 was reviewed on 2/15/12 at approximately 10:00 AM. Pt. #8, a [AGE] year old male, was transferred from another Hospital with an acute MI on 9/26/11. The clinical record contained an operative report, dated 9/27/11 and signed by the surgeon indicating that Pt. #8 was taken to the OR for open heart surgery. The surgical consent dated 9/27/11 was signed by the patient for a coronary artery bypass graft. The surgeon documented that the pt. was placed on a balloon pump but after an 1.5 hours the patient 's heart began failing and that he discussed with the family that the Pt. needed a ventricular assist device (VAD) for support in order for the Pt. to recover from the MI. The family agreed and a tandem heart (VAD) heart was connected without any untoward event. Pt. #8 arrived to the CVICU on 9/27/11 at approximately 10:24 PM. The clinical record contained documentation that a program representative (E#1) was in the OR when the tandem heart (left ventricular heart device) serial number 965 was inserted without complications. Pt. #8 remained with a VAD until 10/3/10 when the device was removed. Pt. #8 was transferred to a specialty hospital on [DATE] for ventilator weaning and was listed as alert, oriented and talking around tracheotomy prior to transfer.
2. Program Representative (E#1) was interviewed by telephone on 2/15/12 at approximately 11:45 AM. E#1 stated that he arrived to the OR and explained the operation of the Tandem Heart to all of the OR nurses prior to the surgical procedure. E#1 also stated that he provided in-services to nursing staff on the CVICU on 9/27, 9/28 and 9/29/11 on monitoring and use of the Tandem Heart device. However, E#1 could not provide any staff in service sign in sheet documentation.
3. The Patient Care Manager (E#3) of 4 West was interviewed on 2/15/12 at approximately 2:30 PM. E#1 stated that she in serviced her staff on the Tandem Heart on 9/27/11 however did not have documentation of the in-service.
4. The Nurse Director of the Operating Room (E#7) stated during an interview on 2/15/12 at approximately 2:40 PM stated that her staff were in serviced by a program representative (E#1): however, E#1 took the sign in sheet documentation .
5. The above findings were verified with the `Director of Risk Management on 2/15/12 at approximately 3:45 PM